Explained: the EU and how it works

Discover how the EU works, how it affects health policy and healthcare services and citizens' access to healthcare throughout the EU.

7 January 2021

The European Union is an economic and political partnership between 27 European countries. The EU consists of 27 countries with a combined population of just over 500 million people. There are currently five official candidate countries; F.Y.R. Macedonia, Turkey, Serbia, Iceland and Montenegro, each at different stages in the process to join; whilst Albania, Bosnia and Herzegovina, and Kosovo are officially recognised as potential candidates.

The United Kingdom ceased to be a Member State on 1 February 2020, but continues to enjoy many of the benefits of membership until 31 December 2020, the end of the current transition period.

Although the EU traces its origins to the six countries that formed the European Steel and Coal Community in 1951, the name ‘European Union’ was actually created by the Maastricht Treaty, which came into force on 1 November 1993.  This built on earlier treaties, which had established, amongst other things, the European single market and the common agricultural and fisheries policies. The Maastricht Treaty introduced new forms of co-operation between the Member State governments, for example, in the area of defence, and thus created a new political, as well as economic, structure. The Maastricht Treaty also included provisions on public health for the first time.

It is estimated that at least half the laws enacted in the UK stem from EU legislation, underlining the hugely influential role it has on many aspects of our lives.

This article gives a brief introduction to:

  • The activities of the European Union are taken forward by a number of bodies - the EU institutions - whose tasks and responsibilities are set out in the treaties.

    The main EU institutions are:

    The European Commission

    The European Commission acts as the EU's executive arm and is responsible for formulating new policies, initiating legislation and the day-to-day running of the EU. It is composed of a President and 27 other Commissioners, supported by approximately 38,000 European civil servants (made up of administrative officials, policy experts, translators, interpreters and secretarial staff). The President is Ursula von der Leyen and the Commissioner for Health is Stella Kyriakides.

    The Council of the European Union

    Sometimes called the Council of Ministers, the Council of the European Union is the EU’s main decision-making body. The European Council, which defines the overall political direction and priorities of the EU, has a President elected by the members of the Council (i.e. the EU member countries), who serves for a term of two and a half years. The current President of the European Council is Charles Michel.

    The Council also meets in other formations to discuss different policy areas. These sectoral Councils are headed by a rotating presidency, with every member state taking the helm for a period of six months. The current holder is Portugal. Meetings are attended by the relevant minister from each country’s national government, depending on the subject, and decisions are usually taken by either qualified majority (voting weighted to take account of population size) or unanimity.

    Health Ministers usually meet once every 6 months as part of the Employment, Social Policy, Health and Consumer Affairs Council (often referred to by its French acronym 'EPSCO'). Each Presidency will set out a number of priority areas for their term, and the EU and health policy page provides information about Austria's health policy priorities. 

    The European Parliament

    The European Parliament (EP) forms the other half of the EU's legislature. Members of the European Parliament (MEPs) are directly elected every five years from all 27 member states (each country has a set number of seats based on its population size). There is no governing party in the Parliament and MEPs do not sit in national blocks but in pan-European political groups. Most EU legislation is now passed according to the 'ordinary legislative procedure' (formerly known as 'co-decision'), under which the Parliament and the Council amend and approve legislation jointly. Where the ordinary legislative procedure doesn’t apply, the Parliament still has the right to be consulted on new legislation. The Parliament also holds the other EU institutions to account, for example by asking Parliamentary Questions, and has the power to reject or censure the Commission and the EU budget.

    The European Courts

    The judicial branch of the EU consists of the European Court of Justice (ECJ) and the Court of First Instance (CFI). Together they interpret and apply the treaties and the law of the EU, and ensure they are applied in the same way throughout the EU. The Court of First Instance mainly deals with cases taken by individuals and companies directly before the EU's courts, and the ECJ primarily deals with cases taken by member states, the institutions and cases referred to it by the courts of member states. Judgements of the European Courts are legally binding and must be implemented throughout the EU, even if they establish rights in areas where there has previously been no EU legislation.

    The EU decision-making process

    The NHS European Office has produced an easy to understand tour through the complex EU decision-making process, involving the EU institutions listed above. Download the chart.

    The EU and health policy page gives more information about EU activities in the area of health.

  • Whilst health policy and the organisation, financing and management of healthcare is a national responsibility of member countries, the EU also undertakes health-related activities, in particular, by supporting co-operation between member states in order to protect and promote public health and to enable the free movement of people around the EU. 

    Public health policy

    Article 168 of the Treaty on the functioning of the European Union sets out the objectives of EU health policy and the underlying legal basis for it. The emphasis is on co-ordination and co-operation, particularly in order to prevent major health threats such as human illness and disease.  

    Examples of the traditional EU-wide public health work include joint actions to address major diseases such as cancer and HIV/AIDs, coordination on health threats including communicable diseases, and major campaigns against drug abuse.

    The scope for EU legislation in the area of health policy is specifically limited, but incentive measures to promote and improve health can be adopted and this provides the basis for the EU4Health 2021-2027 programme, which provides EU funding to support the health agenda. 

    The EU is also responsible for setting policy on plant and animal health and food safety, both areas having important implications for human health. Together with public health and consumer policy, these form the responsibilities of the EU Health Commissioner, supported by the European Commission's Directorate General for Health and Food Safety, often known as 'DG Santé' (a shortened version of its name in French). The Commissioner for Health is Stella Kyriakides.

    Presidency of the Council

    In addition to the agenda taken forward by the European Commission, the country holding the Presidency of the Council will usually set some priorities of its own in the area of health, which it will pursue during its 6-month stint at the helm. Portugal currently holds the Presidency and its main priority will be to deliver a fair, green, digital recover post COVID-19.

    Wider EU policies and health

    The EU also pursues the protection and promotion of health through activities in other policy areas, as the treaties include a general requirement that health should be protected in all Community policies. For example, the EU single market rules provide the legal basis for laws on recognition of professional qualifications which allow healthcare staff to work anywhere in Europe, as well as the EU-wide requirements for health warnings on tobacco products.

    Common minimum standards on employment rights and health and safety at work are also set at EU level, for example, through the Working Time Directive, and developments in these areas are of key importance to the NHS in its role as Europe’s largest employer.

    The European Commission has a legal duty to consult representatives of employers and employees on all employment-related proposals and this is taken forward through a process called social dialogue. The NHS European Office represents the NHS in the EU social dialogue process through our membership of two European social partner organisations, HOSPEEM (representing employers in the hospital and healthcare sector) and CEEP (representing the range of public sector employers).

    The Influencing EU Policy section of our website gives more information about the implications of specific EU policies and initiatives for the NHS. 

    More information about the impact of EU law on the NHS and the NHS' engagement with European affairs can be found in this edition of Eurohealth, a publication from LSE Health and the European Observatory on Health Systems and Policies.

  • European travellers going on a holiday or a business trip to a European Economic Area country (EEA) or Switzerland, can apply for a free European Health Insurance Card (EHIC) from their home country's healthcare system. The EHIC entitles them to receive emergency or immediately necessary healthcare if a need arises during their trip. It does not allow patients to go abroad specifically to receive medical care.

    Information about access to healthcare in the EU for UK residents, including how to apply for an EHIC, and information on planned treatment and healthcare when moving abroad, is available from the NHS Choices website. In particular, if you're having difficulties with the online application form, to update your personal details, or to replace a lost or stolen card, call the automated EHIC application service on 0300 3301350. For general enquiries about the EHIC or claim refunds, call the Overseas Healthcare Team on 0191 218 1999. If calling from abroad ring +44 191 218 1999. Unfortunately, the NHS European Office is not able to give advice on individual cases. A European Commission guide to the social security rights of insured persons moving within the EU is also available. 

    Information about the EHIC scheme

    EHIC cards allow travellers to access the same level of state-provided treatment as a resident of the country they are visiting. In countries which require patients to pay part of the costs of their treatment, travellers will normally be required to do the same.

    The EHIC scheme only covers emergency or immediately necessary treatment, and does not cover any private medical healthcare or the costs of mountain rescue, repatriation or lost or stolen property. With this in mind, it is strongly advisable for travellers to take out additional private travel insurance, including medical cover, before travelling abroad.

    Patients considering travelling to another country specifically for treatment should discuss their plans with their doctor and their health insurer or commissioner before making any travel or medical arrangements.

    A European Commission smartphone application that functions as a guide on how to use the EHIC card has been available since June 2012. The app is available in 24 different languages and includes details on treatments covered by the EHIC card and how to claim reimbursement. Download the app to find out more.

    Information for NHS organisations

    From 12 October 2009, visitors to the UK from EEA countries and Switzerland who require emergency or immediately necessary (unplanned) NHS healthcare are required to provide proof of entitlement to free treatment, usually with a valid European Health Insurance Card ‘EHIC’ or Provisional Replacement Certificate ‘PRC’.

    NHS organisations need to collect EHIC/PRC information and submit it to the DWP Overseas Healthcare Team through the Overseas Visitors Treatment (OVT) Portal - a new easy-to-use web tool. Only through collecting this information is the NHS able to recover costs from patients’ home healthcare systems to reinvest in NHS care.

    EEA visitors who cannot provide a valid EHIC or PRC or other proof of entitlement to free care should be charged for their treatment, according to the Department of Health’s Overseas Visitors Hospital Charging Regulations. It is important to note that they should be treated as NHS charged patients and not private patients. This is because, under European law, EEA patients should be treated on an equal basis to NHS patients, and treating them as private patients, at potential additional cost to them, would not be in line with this unless they have specifically stated that they wish to receive private care. In addition, visitors may be able to reclaim charges from their home system, but some countries will only cover the costs of treatment provided by state healthcare systems and not private healthcare.

    More information on the new requirements is available from the Department of Health website.

    NHS organisations should also be aware that different rules apply when a patient travels to another country specifically for treatment. Our cross-border healthcare page gives more information about the revised rules on patients' rights to cross-border healthcare.

    Reciprocal healthcare post-Brexit

    All of the above may well change at the end of the current transition period, which terminates on 31 December 2020. The UK and EU are in negotiations to develop a post-2020 relationship, where reciprocal healthcare arrangements will be discussed. For more on post-Brexit reciprocal healthcare, visit our dedicated page. See also the latest briefing from the Brexit Health Alliance on what should be prioritised during the negotiations on the future relationship.